trainingWrWritten evidence submitted by the Medical Protection Society (RTR0054)

Executive summary

The Medical Protection Society (MPS) welcomes the opportunity to submit evidence to the Health and Social Care Select Committee inquiry into workforce recruitment, training and retention in health and Social Care.

As a medical defence organisation, we have a particular perspective on this issue and we recognise that there will be other organisations which are better placed to comment on some of the wider solutions to addressing the barriers to workforce recruitment, training and retention.

In our submission we will focus on the areas that we have expertise on and which we believe need to be addressed in order to improve the recruitment, training and retention of staff in the health and social sector for the Committee should consider. We will focus on the below two areas:

1. Supporting healthcare professionals’ wellbeing. MPS has long been warning about the increasing levels of burnout amongst healthcare professionals. We believe and our members tell us that this is a key area influencing their decision to continue exiting their profession.

2. Creating a culture of learning, not blame. MPS has long been an advocate for installing a culture of openness and learning in the healthcare sector, where possible moving away from the current system which facilitates placing the blame on individual healthcare professionals.

We believe that the high level of burnout amongst the profession as well as the fear of facing an investigation is having a negative impact on recruitment and retention of staff. Having a wellbeing strategy as well as creating an open culture which fosters learning will in turn attract workers to the health and social care sector, and these must be considered part of the solution in the medium and long-term.

1. Wellbeing

MPS has long been concerned with the wellbeing of the profession. In 2019, we ran a global campaign on burnout, publishing the report Breaking the burnout campaign which outlines the different factors that lead to burnout. The report detailed what healthcare professionals in the UK were telling us about their experiences of burnout through a member survey[1], and we put forward proposals for how healthcare professionals could be better supported. This was part of an international programme in which as well as the UK we produced reports on burnout in Ireland, South Africa, Australia and New Zealand.

In June 2019, we surveyed MPS members to better understand the impact work was having on their wellbeing. This found that 45% had considered leaving the profession for reasons of personal wellbeing, and 50% do not or not at all feel supported by the regulator[2].

Whilst the sample size was small, many similar surveys carried out by other organisations have found similar consistent results. Nevertheless, these numbers are alarming and show the level of burnout amongst the profession pre-Covid-19, and the high level of dissatisfaction amongst healthcare workers in the UK.

The Covid-19 pandemic has only put more pressure on the workforce, having had a huge impact on an already stretched workforce suffering from high levels of burnout. We believe that adrenaline has carried healthcare workers during the pandemic and helping them to cope despite the exhaustion and tragedy they may be facing, showing an incredible resilience and the willingness to help patients now more than ever.

However, it is when the crisis truly recedes and there is time to reflect that the accumulated stress and trauma may surface - this is the time doctors will be most at risk of burnout and need support.

We believe that even after the worst has passed, Covid-19 will continue to bring pressures and complications, compounded by a significant referral backlog to deal with. The last thing we want is huge swathes of doctors leaving the profession after Covid-19. In order to avoid this, MPS has previously called on the Government, NHS and private healthcare providers to put a plan in place to support the mental wellbeing of healthcare workers as well as a strategy to ensure the system has capacity so that those needing treatment or time to recuperate can take that time without fearing staff shortages.

The NHS People Plan addresses the issue of wellbeing, and we believe it is a step in the right direction as it promotes looking after each other and quality health and wellbeing for everyone, as well as tackling discrimination and looking into the effective use of people’s skills.

We particularly welcome the NHS England and NHS Improvement initiative which has started during Covid-19 and allows all NHS staff on people.nhs.uk to access a dedicated health and care staff support service, including confidential support via phone and text messages, specialist bereavement support and free access to mental health and wellbeing apps, among other services. We also support the NHS England and NHS Improvement pilot approach to improve staff mental health by establishing resilience hubs working in partnership with occupational health programmes to undertake proactive outreach and assessment, and co-ordinate referrals to appropriate treatment and support for a range of needs.

MPS also welcomes the initiative of providing safe spaces for staff to rest and recuperate for staff, so they can manage and process the physical and psychological demands of the work, on their own or with colleagues. However, these initiatives should not be only available during the current pandemic, even if they are a response to it. These should be extended post Covid-19.

However, we do not think this is enough to reduce the risk of workforce burnout across the NHS, since the level of burnout within the sector was already high pre-Covid-19 and further measures are needed to tackle the burnout of healthcare workers.

In particular, we believe that further action could and should be taken to support healthcare professionals facing PTSD as a result of the pandemic. This is the reason why in May 2021, we coordinated a letter alongside other healthcare organisations, including the Royal College of Psychiatrists, in which we encouraged the Government to take inspiration from the service offered to support veterans’ mental health when designing specialist physician-led occupational health services for healthcare workers suffering from PTSD and other conditions as a result of the pandemic. This followed a study from Professor Greenberg[3], looking at staff working in critical care during the pandemic, which showed they report more than twice the rate of probable post-traumatic stress disorder (PTSD) found in military veterans.

We understand that putting a wellbeing strategy in place will take time and therefore it may not solve the short-term recruitment and retention challenges. However, we believe that making the changes we suggest above and having a wellbeing plan in place will have a positive impact on workforce recruitment, and retention in the medium and long term.

2. Creating a culture of learning not blame

The fear of being subject to an investigation is one of the areas which is causing healthcare professionals unnecessary stress and anxiety. Covid-19 has only made this anxiety worse as healthcare professionals do not only have to be fearful of the possible complaints and claims arising from their practice and related to Covid-19 but also to the ones which may arise as a result of delayed referral or the backlog of cases.

In a survey of our members carried out in 2021, nearly 4 in 5 GPs in the UK (77%) said they are concerned about facing investigation if patients come to harm as a result of delayed referrals or non Covid-19 services being unavailable or limited[4]. While this could be read as a statistic derived from the situation with Covid-19, we have previous data that illustrates that the fear of investigation and the persistence of a blame culture is still something that needs addressing.

Our concerns it that a blame culture places too much emphasis on punishment and even criminalisation, while neglecting to nurture a system where mistakes can be learned from and avoided in the future.

Positive reforms to create a more learning culture

We support creating an environment where clinicians feel empowered and confident to admit errors, and learn from mistakes, without fear of incrimination. There needs to be explicit support from leaders who need to be equally committed to the principles of open disclosure, in order for clinicians not to fear being blamed when admitting a mistake. 

In our experience, more often than not, apologising, admitting a mistake and communicating effectively will help to mitigate litigation. However, this is only plausible if there is a change in the current mentality which allows for healthcare professionals to be open about mistakes without the fear of being blamed and subsequently faced with regulatory, civil or criminal proceedings.

Defence organisations have an important role to play in the creation of an open and learning environment. At MPS, we draw on our experience and expertise to raise awareness of the causes of claims, the conditions behind these, and how errors can be prevented. We also aim to reduce the prospect of claims, by offering education programs and advice to our members.

We have also set up our Speaking up for safety initiative which helps healthcare organisations overcome entrenched hierarchical behaviours that can contribute to unintended patient harm. We partner with hospital groups to build and embed a culture of safety and quality by normalising collegiate two-way communication between staff to support each other and speak up any time there is a concern for patient safety.

Reforms to address the blame culture in the NHS

Alongside the above-mentioned proposals that would proactively promote a learning culture, we strongly support reforms aimed at addressing the way in which individual healthcare professionals are held to account for adverse incidents in patient care.

Two separate reviews, the Williams review into Gross Negligence Manslaughter in Healthcare and the Hamilton Independent Review into Gross Negligence Manslaughter and Culpable Homicide, have look into this in the past four years exploring how GNM charges are applied in healthcare settings. Both reviews suggest a set of measures which include taking into account systemic issues when investigating doctors’ for gross negligence manslaughter, supporting the

development of a “just culture” in healthcare.

We believe that the current threshold of what constitutes gross negligence manslaughter in England and Wales also needs to be looked at.  For example, a striking feature of the current legal position on gross negligence manslaughter in England and Wales – unlike Scotland – is that neither ‘disregard’ nor ‘recklessness’ are required for a conviction. Over the past two decades, there have been cases of medical professionals and patient mortalities involving momentary – yet significant – errors, with no evidence of either recklessness or disregard on the part of the doctor, but still resulting in conviction.

By way of contrast, in Scotland, the nearest comparable offence is that of culpable homicide.

Under Scottish law, culpable homicide is the killing of a person in circumstances which are neither accidental nor justified, but where the wicked intent to kill or wicked recklessness (required for murder) is absent. The tests for distinguishing both murder and culpable homicide are objective.

We believe that the current legal bar for convicting healthcare professionals of manslaughter in England is too low. Everyone loses in such cases. A family has lost a loved one; a doctor risks losing their career and liberty; our NHS, already under considerable pressure, potentially loses a valuable doctor as well as suffering the untold damage to an open, learning culture.

While the number of GNM cases in the UK are low, we have seen in recent years the impact that these cases have on the wider profession and the fear that they can create. Therefore, while we fully appreciate that the Committee will be considering a wide range of proposals for improving workforce retention that will have a more significant causal impact, we recommend that the Committee also considers the positive impact that progress in this area could have.

In addition, we strongly support reforms aimed at ensuring a more proportionate approach to professional regulation.

There are few developments that worry a healthcare professional more than receiving a letter from their professional regulator. This is why it is vital that their investigations are carried out efficiently, fairly, sensitively and proportionately.

The vast majority of GMC and GDC investigations are closed without action, the end result being that far too many doctors and dental professionals go through a stressful process each year, while many complainants also endure a lengthy process with a disappointing outcome.

We have long argued for reforms to the Medical Act and Dentists Act to enable the GMC and GDC to streamline their processes, improve efficiency, reduce the number of investigations into less serious allegations, and conclude investigations in a more timely manner, giving them discretion to not take forward investigations where allegations clearly do not require action. The status quo serves neither doctors nor patients and could be a factor impacting the recruitment and retention of workers within the health and social care sector.

Another key reform which the government must still act on is the removal of the GMC right of appeal MPTS decision. In 2018, the government accepted in full the recommendations of the Williams review into gross negligence manslaughter in healthcare, following the case of Dr Hadiza

Bawa-Garba. The independent review concluded that, following the case of Dr Bawa-Garba, removing the GMC’s right of appeal against MPTS decisions would ‘help address the mistrust of the GMC amongst doctors and contribute to cultivating a culture of openness that is central to

delivering improved patient safety’. We have persistently call on the government to deliver on its promised and coordinated a joint letter urging the Secretary of state for Health to deliver on its commitment in March 2021.

Again, while we fully appreciate that the Committee will be considering a wide range of proposals for supporting the workforce that will have a more significant causal impact on retention and engagement, we recommend that the Committee also considers the positive impact that could be achieved through reforms to professional regulation.

About MPS

MPS is the world’s leading protection organisation for doctors, dentists and healthcare professionals with more than 300,000 members around the world.

Our in-house experts assist with the wide range of legal and ethical problems that arise from professional practice. This can include clinical negligence claims, complaints, medical and

dental council inquiries, legal and ethical dilemmas, disciplinary procedures, inquests and

fatal accident inquiries.

MPS is not an insurance company. We are a mutual non-for-profit organisation and the benefits of membership of MPS are discretionary as set out in the Memorandum of Articles of Association.

January 2022